Healthcare Provider Details

I. General information

NPI: 1144254079
Provider Name (Legal Business Name): PREMIER HOSPITAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5326 PAN AMERICAN RD NE
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 93725 5326 PAN AMERICAN RD NE
ALBUQUERQUE NM
87199-3725
US

V. Phone/Fax

Practice location:
  • Phone: 505-341-4914
  • Fax: 505-341-4916
Mailing address:
  • Phone: 505-341-4914
  • Fax: 505-341-4916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number407NM
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. DARREN D MAESTAS
Title or Position: PRESIDENT
Credential:
Phone: 505-341-4914